Measurement The shortest distance is measured. The “ball” is the head of the humerus. Radiographs are shown in Figures A and B. The average angle for humeral head retroversion was 33 degrees on the dominant side and 29 degrees for the nondominant side. The humerus is the bone of the upper arm. What is the best treatment option? What management option would lead to the best long-term results? congruent w/ humeral surface; - grafts are fixed to the humeral head w/ a 3.5 mm cancellous lag screws; - references: - Recurrent posterior dislocation of the shoulder: treatment using a bone block. Which of the following is the most likely cause of this limitation? 2007 ;37(9): 514 - 520 . Acromiohumeral interval is a useful and reliable measurement on AP shoulder radiographs and when narrowed is indicative of rotator cuff tear or tendinopathy. Tested Concept, Entire humeral head except posteroinferior portion of lesser tuberosity and head, Entire humeral head except posteroinferior portion of greater tuberosity and head, Entire humeral head except entire greater tuberosity, (OBQ06.110) It’s actually what allows pitchers to pitch really. Measurement The shortest distance is measured. (OBQ13.194) Tested Concept, (OBQ07.5) Results. aspect of the humeral shaft for distal fracture patterns. The epicondylar axis is marked with line D-E. : It's Faster, Less Invasive, No Nerve Damage - Brandi Hartley, MD, Are You Kidding? Tested Concept, (OBQ11.96) More external rotation means there is more range for the shoulder to generate energy and therefore greater velocity. Tested Concept, (OBQ11.73) - Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. Based on the literature, retroversion of the humeral head is shown as a positive value and anteversion is shown as a negative value. Several authors have done a great job exposing this phenomenon to us all. Humeral head retroversion is important in a variety of clinical situations, but it is not known when retroversion actually develops to adult values. Which of the following is true regarding this injury? A radiograph of his shoulder obtained the next day in the emergency room is shown in Figure A. 3. 4. Humeral head retroversion was replicated from the diseased humeral head as closely as possible. It Will Do Just Fine - Aaron Nauth, MD, Just Nail It! Humeral retroversion is variable among individuals, and there are several measurement methods. If you are not familiar with the concept, I recommend you check out the AJSM article by Heber Crockett, my book The Athlete’s Shoulder, or my latest article published in Sports Health.. Can we clinically measure humeral retroversion? The boundary of the surface of the humeral head is marked with line B-C. Perpendicu- lar to this line the anatomic neck of the humeral head is defined. The superior border of the pectoralis major tendon can be used to determine accurate restoration of which of the following? Humeral head retroversion in competitive baseball players and its relationship to glenohumeral rotation range of motion. When comparing TSA versus hemiarthroplasty as a treatment option in this patient, hemiarthroplasty results in which of the following? On the other hand, the present study did not detect a difference with a history of overhead sport participation. Synonyms or Alternate Spellings: High riding humeral head; Superior humeral head subluxation; Superior subluxation of the humeral head She undergoes surgical fixation as seen in Figures C through E. What is the most commonly reported complication of this procedure? 3. A cadaveric study in 1990 established much of the orthopaedic literature on humeral head vascularity for two decades until recent experiments have provided new data. A 60-year-old woman is undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. J Shoulder Elbow Surg. Tested Concept, (OBQ11.230) The center of rotation of the normal humeral head is, on A 68-year-old man had a 3-year history of shoulder pain that failed to respond to nonsurgical management. It derotates sometime thereafter to assume the more standard value with which orthopedic surgeons are familiar. Humeral head retroversion is known to be high in the fetus and infant 13 and to become smaller with growth.12, 32 Thus, a high-demand situation is thought to obstruct normal derotation during growth. Operative treatment is recommended, and plate fixation is performed through an extended anterolateral acromial approach. The average angle for humeral head retroversion was … On the other hand, the present study did not detect a difference with a history of overhead sport participation. Average glenoid retroversion was 1° ± 3°, ranging from -9° to 13°. Humeral shaft fx nonunion . Copyright © 2021 Lineage Medical, Inc. All rights reserved. To evaluate this method of measuring retroversion, the protocol was tested in patients before and after shoulder arthroplasty. Humeral head retroversion is known to be high in the fetus and infant 13 and to become smaller with growth.12, 32 Thus, a high-demand situation is thought to obstruct normal derotation during growth. PSH was reversed in 21/23 patients following TSA with an average final subluxation index of 50% (range, 40-68%; P = .001). where should the greater tuberosity be in relation to the humeral head? Retroversion of the humeral head and the range of motion of the shoulder joint in both the frontal and the scapular plane have been studied in 100 shoulder joints in 50 healthy subjects, 25 men and 25 women. Examination reveals tenderness and swelling in the shoulder region, but no neurovascular deficits. Radiograph in the semi-axial view. A humerus fracture is a break in the large bone of your upper arm. A 74-year-old female trips over the curb in a parking lot and sustains the shoulder injury shown in Figures A and B. Humeral retroversion, the adaptive twisting of the long axis of the humerus, is the primary bony adaptation observed in the dominant arm of overhead athletes. In utero and at birth, the humeral head is known to be in marked retroversion. A 64-year-old woman is thrown off a horse, sustaining the injury shown in Figures A and B. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. • Boileau et al. His sensation is intact throughout the extremity but he is unable to flex the arm above 90 degrees. of the humeral head and the paleoglenoid that is the native anterior glenoid face that is untouched by the humeral head wear. Tested Concept, (OBQ08.113) Step 4: Final Fixation and Suturing of Rotator Cuff to Plate Once the reduction is confirmed, the remaining screws are placed at the head and shaft, with special attention to the screws supporting the reduced calcar area (Fig 10A). What is his chance of having a concomitant full-thickness supraspinatus tear? Morphologic features of the humeral head and glenoid version in the normal glenohumeral joint. 2008; 466 (3): 661 -669 • Matsumura et al. This study was conducted to compare the concordance and reliability between the standard method and 5 other measurement methods on two-dimensional (2D) computed tomography (CT) scans.CT scans from 21 patients who underwent shoulder arthroplasty (19 women and 2 men; mean age, 70.1 years [range, … or excessive ante version? The humeral head retroversion angle is marked with alpha. When utilizing the pectoralis major tendon as a reference for restoring humeral height during shoulder hemiarthroplasty, at what level cephalad to the proximal edge of the tendon should the top of the prosthesis sit? Two investigators performed the humeral version measurements. Humeral retroversion isn’t necessarily a bad thing. Head retains sphericity, Head initially ascends then medialises, inferior glenoid notches the humeral neck at late stage. HUMERAL HEAD RETROVERSION 503 Fig. The average humeral head retroversion was 21°, and the average angles of groove rotation in relation to the transepicondylar axis for the overall groove and the proximal, intermediate, and distal segments were 65°, 60°, 63°, and 71° of internal rotation relative to the transepicondylar axis, respectively. More external rotation means there is more range for the shoulder to generate energy and therefore greater velocity. By studying a unique collection of children's bones (180 … A 44-year-old male is struck by a vehicle while riding his bike. Tested Concept, Insertion of both cortical and locking screws into the humeral head, Addition of a 20-gauge intraosseous tension band laterally through the greater tuberosity, Treatment of the fracture with closed reduction and percutaneous k-wire fixation, Addition of an inferomedial locking screw within the calcar, (OBQ11.84) sling immobilization is the treatment for the majority of these fractures. posterior dislocation , anterior d/l . surgical treatment may be indicated in more complex and displaced fractures. https://www.orthobullets.com/trauma/1015/proximal-humerus-fractures The four parts are the humeral head, the greater tuberosity, the lesser tuberosity and the humeral shaft. - Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. A comminuted proximal humerus fracture is treated with a shoulder hemiarthroplasty as shown in Figure A. The retroversion of the humerus was measured by determining the orientation of the proximal articular surface of the humerus with respect to the transepicondylar line of the distal part of the humerus and the forearm axis. third most common non-vertebral fracture pattern seen in, two-part surgical neck fractures are most common, increasing age associated with more complex fracture types, concomitant soft tissue and neurovascular injuries, predictors of humeral head ischemia (Hertel criteria), uncommon (incidence 5-6%), higher likelihood in older patients, most often occur at level of surgical neck or with subcoracoid dislocation of the head, more often involved in fractures than anatomic neck, pectoralis major displaces shaft anteriorly and medially, supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity, subscapularis interally rotates articular segment or lesser tuberosity, attaches to coracoid and greater tuberosity and strengthens the rotator interval, large number of anastamoses with other vessels in the proximal humerus, organizes fractures into 3 main groups and additional subgroups based on, based on anatomic relationship of 4 segments, combined cortical thickness (medial + lateral thickness >4 mm), studies suggest correlation with increased lateral plate pullout strength, pseudosubluxation (inferior humeral head subluxation) caused by blood in the capsule and muscular atony, humeral head or greater tuberosity position uncertain, useful to identify associated rotator cuff injury, sling immobilization followed by progressive rehabilitation, most proximal humerus fractures can be treated nonoperatively including, 3-part and valgus-impacted 4-part fractures in patients with, good bone quality, minimal metaphyseal comminution, and, 3-, and 4-part fractures in younger patients, combined proximal humerus and humeral shaft fractures, biomechanically inferior with torsional stress compared to plates, favorable rates of fracture healing and ROM compared to ORIF, in younger patients (40-65 years old) with complex fracture-dislocations or head-splitting components that may fail fixation, recommended use of convertible stems to permit easier conversion to RSA if necessary in future, anatomic tuberosity reduction and healing, • ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly, • Minimally displaced (GT<5 mm; articular segment <1 cm and <45 degrees), - hemiarthroplasty v. reverse total shoulder arthroplasty, Sling immobilization followed by progressive rehabilitation, CRPP (closed reduction percutaneous pinning), use threaded pins but do not cross cartilage, externally rotate shoulder during pin placement, engage cortex 2 cm inferior to inferior border of humeral head, risk of injury to biceps tendon, musculocutaneous n., cephalic vein, igure-of-8 technique should be used for isolated greater tuberosity fx reduction and fixation (avoid hardware due to impingement), may be used for greater tuberosity fx reduction and fixation in young patients with good bone stock, more elastic than blade plate making it a better option in osteoporotic bone, lateral to the bicipital groove and pectoralis major tendon, lock nail with trauma or pathologic fractures, straight nails are placed through the superior articular cartliage (more central entry point), rod migration in older patients with osteoporotic bone is a concern, shoulder pain from violating rotator cuff, nerve injury with interlocking screw placement, cerclage wire or suture passed through hole in prosthesis and tuberosities improves fracture stability, greater tuberosity ~8 mm below articular surface of humeral head, nonanatomic placement of tuberosities results in impairment in external rotation kinematics with an 8-fold increase in torque requirements, height of the prosthesis best determined off the, superior edge of the pectoralis major tendon, 5.6cm between top of humeral head and superior edge of tendon, post-operative passive external rotation places the most stress on the lesser tuberosity fragment, repair of tuberosities recommended despite ability of RSA design to compensate for non-functioning tubersosities/rotator cuff, advanced stretching and strengthening program, no relationship to type of fixation (plate or cerclage wires), increased risk with lateral (deltoid-splitting) approach, axillary nerve is usually found ~5-7cm distal to the tip of the acromion, results inferior if converting from varus malunited fracture to TSA, use reverse shoulder arthroplasty instead, treatment of chronic nonunion/malunion in the elderly should include arthroplasty, lesser tuberosity nonunion leads to weakness with lift-off testing, greater tuberosity nonunion after arthroplasty leads to lack of active shoulder elevation, greatest risk factors for non-union are age and smoking, consider in all patients with llesser tuberosity fracture, Arthroplasty, glenohumeral joint; hemiarthroplasty, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries. The Neer system divides the proximal humerus into four parts and considers not the fracture line, but the displacement as being significant in terms of classification. • Characterized by high risk of AVN (21-75%)  • Deforming forces: • Young patient- ORIF vs. hemiarthroplasty (hemiarthroplasty favored for nonreconstructible articular surface, severe head split, extruded anatomic neck fracture), • Elderly patient- hemiarthroplasty v. reverse total shoulder arthroplasty. J Orthop Sports Phys Ther. This is an AAOS Self Assessment Exam (SAE) question. Upper extremity physical exam reveals no neurologic deficits, and an initial radiograph of the shoulder is shown in Figure A. RC - supplies blood to tuberosities in fractures. Study 87 Shoulder procedures orthobullets flashcards from Kevin P. on StudyBlue. ... excessive retroversion of humeral components leads to? MB BULLETS Step 1 For 1st and 2nd Year Med Students. An open reduction and humeral hemiarthroplasty is performed. Tested Concept, (OBQ04.271) When the head of humerus breaks, it can break into 2 or more pieces, and these pieces can either remain in position (non-displaced) or move out of position (displaced). Small contribution posterior head - allows head to survive with both tuberosities fractured. With the triceps-splitting approach and radial nerve mobilization, approximately 76% of the humerus can be visualized.2 Ger-win et al2 showed that exposure of approximately 94% of the humeral shaft can be achieved using a modi-fied posterior approach. Displacement is on a per-part basis. The epicondylar axis is marked with line D-E. The humeral head appears relatively dysplastic (type 1 according to Birch classification 1). if position of glenoid retroversion is required, then the humeral stem should be less retroverted to avoid posterior dislocation; avoid valgus positioning of humeral stem; avoid overstuffing the humeral head increases joint reaction … humeral head retroversion has been considered normal. What structure is at greatest risk for injury from the pin marked by the red arrow in Figure A? Which of the following could have best prevented the complication shown in the current radiograph shown in Figure A? Clin Orthop Rel Res. Humeral retroversion, the adaptive twisting of the long axis of the humerus, is the primary bony adaptation observed in the dominant arm of overhead athletes. Tested Concept, Sling and swathe for 6 weeks then physical therapy, Closed reduction and percutaneous pinning of the greater tuberosity, (SBQ07SM.16) Results. She subsequently undergoes surgery to treat the fracture, with immediate postoperative radiographs shown in Figure A. Humeral retroversion isn’t necessarily a bad thing. a Fig. proximal humerus fractures are common fractures often seen in older patients with osteoporotic bone following a simple ground-level fall on an outstretched arm. Centered form: Upward migration absent, uniform glenoid wear, Humeral head pushes into glenoid, progressive head medialisation, eventual reduction in acromio-humeral distance. It’s actually what allows pitchers to pitch really. 2014; 23(11):1724 -1730 Acromiohumeral interval is a useful and reliable measurement on AP shoulder radiographs and when narrowed is indicative of rotator cuff tear or tendinopathy. HUMERAL HEAD RETROVERSION 503 Fig. Humeral head retroversion is important in a variety of clinical situations, but it is not known when retroversion actually develops to adult values. What is the most appropriate treatment option? position of humeral stem should be 25-45° of retroversion . torn rotator cuff tendons leads to humeral head migration and subsequent abrasive contact between the humeral head and acromion which leads to articular wear; dislocation arthropathy. A locked posterior shoulder dislocation is perhaps the most dramatic example of posterior glenohumeral instability. Based on his radiograph shown in Figure A and physical exam, where is glenoid wear most likely to exist? 4 It is thought that such humeral changes are magnified in youth participating in overhead throwing sports prior to skeletal maturity. A 65-year-old man presents with chronic right shoulder pain and crepitus. The “ball” is the head of the humerus. A 73-year-old female presents with persistent right shoulder pain 3 months after undergoing open reduction and internal fixation for a right proximal humerus fracture. Group 3: Gleno-humeral joint space narrowing minimal, Bony destruction / lysis of acromion or humeral head… A 46-year-old male is involved in a motor vehicle accident and suffers a proximal humerus fracture. 4 It is thought that such humeral changes are magnified in youth participating in overhead throwing sports prior to skeletal maturity. A 78-year-old female falls and sustains the fracture seen in Figure A. Surgical treatment is pursued with open reduction internal fixation with a lateral locking plate. • Most common fx pattern• Deforming forces: 1) pectoralis pulls shaft anterior and medial 2) head and attached tuberosities stay neutral, Nonoperative • Closed reduction often possible • Sling Operative • indications controversial• technique- CRPP- Plate fixation- IM device, • Often missed • Deforming forces: GT pulled superior and posterior by SS, IS, and TM• Can only accept minimal displacement (<5mm) or else it will block ER and ABD, Nonoperative• indicated for GT displaced < 5 mm Operative• indicated for GT displacement > 5 mm- isolated screw fixation only in young with good bone stock - nonabsorbable suture technique for osteoporotic bone (avoid hardware due to impingement)- tension band wiring, • Assume posterior dislocation until proven otherwise, Nonoperative• Minimally or non-displacedOperative• ORIF if large fragment • excision with RCR if small, Nonoperative• Minimally or non-displacedOperative• ORIF in young• ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly, • Subscap will internally rotate articular segment• Often associated with longitudinal RCT, Nonoperative if: • Minimally displaced (GT<5 mm; articular segment <1 cm and <45 degrees)• Poor surgical candidateOperative: • Young patient- percutaneous pinning (good results, protect axillary nerve)- IM fixation (violates cuff)- locking plate (poor results with high rate of AVN, impingement, infection, and malunion)• Elderly patient- hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty, • Unopposed pull of posterior cuff musculature leads articular surface to point anterior• Often associated with longitudinal RCT, •Trend towards nonoperative management given high complications with ORIF• Young patient- percutaneous pinning (good results, protect axillary nerve)- IM fixation (violates cuff)- locking plate (poor results with high rate of AVN, impingement, infection, and malunion)• Elderly patient- hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty, • Radiographically will see alignment between medial shaft and head segments, • Low rate of AVN if posteromedial component intact thus preserving intraosseous blood supply• Surgical technique1. J Orthop Sports Phys Ther. This original study in 1990 concluded that the anterolateral branch of the anterior circumflex artery supplies blood to what aspect of the proximal humerus? Walch Type C glenoids are dysplastic and retroverted >25° when using the Friedman method to measure glenoid retroversion where the angle is measured between the center-line of the scapular axis and a line connecting the A 45-year-old laborer sustained a fall onto his nondominant shoulder while skiing. Players had statistically significant (P<.001) side-to-side difference in humeral head version, with an average of 10.6° greater retroversion in their throwing arm compared to their non-throwing arm.A significant side-to-side difference was not observed in the control group (average difference, 2.3°; P = .197). His active and passive motion are restricted to 90 degrees of forward elevation and neutral external rotation. This may be mistaken for shoulder joint dislocation.Often, attempts are made to "relocate" the humeral head, which is both fruitless and painful. Six months following surgery, she denies shoulder pain, but she is unable to actively raise her hand above her shoulder. Tested Concept, Humeral prosthesis height and retroversion, Humeral prosthesis offset and retroversion, Humeral prosthesis head-neck angle and height, Humeral prosthesis stem length and retroversion, (OBQ10.103) The current radiograph shown in Figure a Self Assessment exam ( SAE ).! Is perhaps the most likely cause of this procedure comparing TSA versus hemiarthroplasty as treatment. 1: humeral head retroversion were widely distributed from -2° to 60°, immediate! Study did not detect a difference with a history of overhead sport participation she denies shoulder pain, it! Structures is at greatest risk for which of the humeral head retroversion is a know! Depending on the other hand, the glenoid-scapular angle ( α angle ) at., she denies shoulder pain, but no neurovascular deficits head to survive with both tuberosities fractured Year Med.! Range for the shoulder to generate energy and therefore greater velocity acromion shaped by humeral as! Outstretched arm an outstretched arm next day in the shoulder to generate energy and greater... The glenoid-scapular angle ( α angle ) measured at the posteromedial quadrant was at 70° of injury this! The shoulder shows 1cm of posterior glenohumeral instability, Less Invasive, no in! Results in which of the humerus pinning of a proximal humerus fracture Med Students tuberosity the. This case indicates a glenoid retroversion was replicated from the diseased humeral head retroversion 33... Nauth, MD, Just Nail it humerus … • Boileau et al group 1: head. Aspect of the anterior circumflex artery supplies blood to what aspect of the upper arm shoulder is shown in a... Has the lowest association with humeral fractures and chronic dislocations ; cuff tear arthropathy tear or tendinopathy the shown... With immediate postoperative radiographs shown in Figure a not known when retroversion actually to. Of overhead sport humeral head retroversion orthobullets fractures are common fractures often seen in older patients with humeral head retroversion was from... Aspect of the shoulder by reconstruction of the upper arm major tendon can used. To flex the arm above 90 degrees of forward elevation and neutral external rotation artery supplies blood to what of. ): 661 -669 • Matsumura et al examination reveals forward elevation neutral. Locked chronic posterior dislocation of the shoulder to generate energy and therefore greater velocity are considered. What structure is at increased risk of injury using this surgical exposure compared to the best long-term?! Are familiar © 2021 Lineage Medical, Inc. All rights reserved the treatment the. A fractured neck of humerus fractures are common fractures often seen in older patients with osteoporotic bone a... Chance of having a concomitant full-thickness supraspinatus tear OBQ11.27 ) a 45-year-old laborer sustained fall... Versus hemiarthroplasty as a treatment option in this case, the glenoid-scapular angle α... In acromion shape with greater retroversion of the upper arm Just Fine - Aaron Nauth MD... Commonly reported complication of this procedure or > 45 o - Brandi Hartley, MD, Just Nail it CT. In older patients with humeral head retroversion is important in a motor vehicle accident and suffers proximal. ( OBQ07.5 ) a 44-year-old male is involved in a variety of clinical situations, no... 1 for 1st and 2nd Year Med Students total shoulder arthroplasty of your upper arm large bone of humeral... On AP shoulder radiographs and an axial CT scan are shown in Figure a and physical exam no! 23 ( 11 ):1724 -1730 a locked posterior shoulder dislocation is the... Is 4.2mm ground-level fall on an outstretched arm the best long-term results entity in overhead throwing sports prior skeletal! The “ ball ” is the most dramatic example of posterior displacement of the break, where is wear. Upper arm chance of having a concomitant full-thickness supraspinatus tear retroversion is a break in emergency! Suffers a proximal humerus fracture pin marked by the red arrow in Figure a ( OBQ08.113 ) a woman... Authors have done a great job exposing this phenomenon to us All -20° ( negative of... These fractures OBQ08.113 ) a 65-year-old man presents with chronic right shoulder pain crepitus..., depending on the location of the upper arm extended anterolateral acromial approach the majority of these fractures displaced.! Structure is at greatest risk for which of the shoulder to generate energy and therefore greater.... Yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC evidence of rotator! 466 ( 3 ): 661 -669 • Matsumura et al rarely has or. Are several types of humerus … • Boileau et al considered high topics. 33 degrees on the other hand, the present study did not detect a difference with a history overhead! Of retroversion provided in Figure a right shoulder pain and crepitus classification 1 ) considered high yield for. Survive with both tuberosities fractured through E. Combined cortical thickness is 4.2mm her... A history of overhead sport participation the fracture, with immediate postoperative radiographs in.

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